Anthony D Evans Contact

For your renewal to be accepted, please complete this page in full.

Your Details			Your Address
Title			Street Address
First Name			Suburb
Last Name			Town
E-Mail			County
Telephone			Postcode

Renewal Details

Renewal Premium

Reg No

Broker Ref

2nd Broker Ref

(only required if renewing a 2nd policy ie Roadside Assistance / Recovery)

Is this a Horsebox/Motorcycle Carrier Policy?	Yes No
Current Mileage

Yes No	Have you or any known driver had any accidents, claims, thefts or losses in respect of any motor vehicle that we are not aware of?
Yes No	Have you or any known driver had any convictions, fixed penalty points, been disqualified or is any prosecution pending?
Yes No	Are there any other details that may have changed, or any details that you are unsure to disclose to us?

I/we declare that the answers given above (on which the Underwriters will rely in deciding whether to accept the risk) are true to the best of my knowledge and belief, and that the vehicle described is in a roadworthy condition and that no information has been withheld by me/us that might influence the underwriters acceptance and assessment of this insurance, and to accept a policy subject to the terms and conditions therein.

Please Note: Anthony D Evans & Co. Insurance Brokers require you to provide complete & accurate information, throughout the lifetime of a policy & at renewal. If you are unsure in respect of the above; please contact us for guidance.

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If you have not received any communication / confirmation of cover from us within 1 working day of submitting this request, please contact us on 02476 595812, or email us at enquiries@anthonydevans.co.uk.